Loretto High School School-Based Therapy Referral Form
By completing this form you will notify your school's counselor and School-Based Therapist to refer an LCSS student.  This form is confidential and only shared with the school counselor and therapist to initiate the referral process.  Please note that if the student is already seeing a mental health provider, a referral to the School-Based Therapist may not be made, but they will reach out and make that appropriate decision with the legal guardian. Thank you for caring for our student's well being!
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Student Name *
What grade is the student in?
Clear selection
Brief description of what concerns you see.
Phone
Person referring the student *
Phone number of person referring student
Email of the person referring student *
Is this the student's first time seeing a therapist?
Clear selection
Is there DCS involvement in the family (i.e., Juvenile Justice, CPS investigation)?
 *
Is the student in foster care (state/DCS custody)?
Clear selection
Submit
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